22 June 2009

It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.

But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.

Not surprising in the least. I'm actually astonished that there's anybody with the chutzpah to defend extended work hours for residents. I did my residency largely in the pre-hour-restriction era -- there were hour restrictions on months in the ER, but effectively none for the off-service rotations -- and it was a terrible way to deliver care. I did my time of q3 call in the units and q2 call on surgical services. This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital. That gives a new meaning to being a "resident physician!" (Actually, that's the original meaning, if you must get picky about it.)

The care provided was just scary. I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte. And I did get through it better than most. But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes. I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight. Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it! Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up. But I apparently did it by reflex without actually achieving a state of full wakefulness. This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight. Great training, but not so great for the patients who were the victims of the mistakes.

It seems to me that the defenders of the status quo have donned their rose-colored glasses. They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment. And there's the faux toughness: "I got through it, they can, too if they're not too weak." And the old guard romanticize the qualities of the "true physician" in their dedication to their patients above all else: "These younger doctors just don't care enough."

What a load of crap.

Look, it's with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drviers, airline pilots, etc), and it's stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors. When it's inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.

I also question the motivations of some of those who defend the status quo. It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government's dime are the ones to insist that the situation is just fine, or that "the evidence of benefit is lacking." How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on "efficacy, safety and cost" before making any changes? That's balls! It's also fairly blatant obstructionism and should not be given any credence.

Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.

I would also take issue with Dr Bob's comment that this "training system that has served our profession well for many years." I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I'm sorry, "rigorous") environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.

It is true that change might be painful. Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians. This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers. Maybe it doesn't make sense to have a surgical resident "running the book" -- many surgical residents never see the inside of the OR till their second and third years. The universities might have to hire PAs or NPs for the "scut work" instead of using MDs in training as glorified secretaries (what a waste of time and money).

I'm glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations. The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules. That effected the desired change, I can tell you! Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.

11 comments:

Great post. About hiring physician extenders to do scut work: at least at the hospitals where I've been training in medical school, I'm not sure this is needed. I find that most of the scutwork that is passed along to me (especially in high, undiluted quantities during my Surgery clerkship) is the result of other people simply not doing their jobs (mostly nurses and social workers). While I like and work well with most of the ones I encounter, I've found that our overarching local work ethic just isn't up to snuff, and the systems that the hospital uses don't facilitate efficiency. Except on the Surgery clerkship, rarely has scut work been explicitly within the realm of stated duties of the intern or resident (documentation, calling consults, changing dressing, etc.), and in those cases, I think those are responsibilities that the interns/residents should continue to have.

thanks posting on this very important subject of medical education. during his residency training, i remember my husband's telling me his falling asleep in front of a patient at his clinic after a 72-h-straight transplant call. since his training the rules are implemented to reduce the number of work hours during residency. i do not buy the argument of necessity for hours in its current form to sufficiently train a physician. i believe the training hours can be improved by exposing them to more volume of actual patient care beginning with the med school. our liability rules are quite restrictive to extend this training to the students at an earlier time. also as you mentioned, if the amount of scutwork were reduced, there would be more time to do hand-on work and get involved in critical thinking process. providing opportunities to go to more populated areas of the world, where any kind of medical help is a welcome, might also help with increasing the training hours. i know many european med students use this opportunity to expand their experience. on the exemplary training of our physicians, i would credit more the selection process, pre and post-med school intellectual training of the students than the gruesome work hour demands. besides, many foreign graduate doctors are complemented on their clinical skills even some might fall short on their knowledge of most recent research findings. even though i agree that a proficient training of doctors must encompass extensive exposure to hands on clinical work, achieving this goal can be improved.

Of course, anyone: social work, nurse, attending, and resident can lapse at the job.

I was an MSW student doing my hours in acute rehab, discharge planning, at a regional trauma hospital. I worked 15 hours a week and ran around ragged...

The staff assumed I was employee, and did not realize that I was only an unpaid student.

Sometimes it seemed that we were the secretaries of the attendings and the PTs and OTS.

But seriously, the residents were truly swamped with the secretarial work...seriously...all the dictations and paperwork from hell. The social work students were the ones that called 15 "skilled" nursing homes to find a bed for a medicaid client...

It seems to me the hours restriction should be coming from the top down. In an academic situation this is not so much a problem, but out in the community, it is not unusual to see surgeons taking q.3 or q.4day calls w/ 36 hour shifts. My husband is a community pulmonologist, but b/c the hospital will not hire any intensivists, he is forced into q.2 to q.4 day calls w/ 36 hour shifts. If we argue that 20-somethings cannot make decent managment decision after hour #24, imagine a 40-something year old doing out in the community.

Mommy Doc -- I agree completely. Harder to enforce, of course, because there's no governing body like the ACGME. 'Course you can just say no, which may or may not be bad for your career, and it a pretty untenable position to put individual practitioners in...

I finished my surgery training at the end of the 'unlimited' work-hour week. I never got to experience the 80 hour work week....until I went back and did my fellowship training 4 years after my surgery residency.

The 80 hour work week ensured that I got adequate time to read, prepare for cases, and sleep. It was humane and efficient.

During my years as a resident on q3 call, and up ALL night operating on days we were on call- I can attest that patient care was a little rough around the edges.

But you get through it, and learn a bit about what humans are capable of doing.

Surgical training is all about graduated responsibility. There is work to be done at all levels. Stick around long enough, and you start getting to do the 'good stuff'. Some of the job involves doing paperwork- and that is what non-physician extenders should be used for.

Good post. But you did say 'good training'. This is often mentioned by the old guard as well, that it's good training to see lots of patients and see how tough you are.

This attitude ignores everything we know about learning. The brain does not retain well, or learn well, when at its limits. It also does not learn well when we feel emotionally resentful. To say getting worked over on morning rounds is 'good training' is also a load of crap. Everything we know about sleep physiology also teaches us that you can't really train yourself to somehow overcome the effects of staying up; rather, it just gets harder as you get older. Learning to think in a crisis is a matter of exposure to crisis, not exposure to 30 straight hours of paperwork and rounding.

When it comes down to it, residents get used the way they do to put money in the pockets of the institution and so people don't have to do paperwork. I have learned from seeing patients, but I have never learned a damn thing from the paperwork.

This is they dying edge of a machismo culture that is bad for patients all around and bad for us as physicians, too. Good thing I picked a field where I work for no more than 12 hours at a time, about 16 times a month. Hah.

Great post!! I've been thinking about this a lot recently, coming up to intern year and seem to have heard all the arguments from the other side of the fence recently (how will they ever get enough experience, they won't have worked hard enough/seen enough patients), and having seen myself fairly sleep deprived without patient responsibility, I would much rather go with the "humane" way, even if it means training for longer. If I am that sleep deprived that I am walking into walls, I am sure I would be a danger to patients and anyone on the road when driving home.

There seems to be two different issues at work here. The first is the important issue of work hour restrictions for residents, which I whole-heartedly agree with you on. The residency schedule is abusive and the fatigue and anxiety generated are probably very counter-productive to learning, not to mention unsafe for both patient and doctor. Residency should focus on the quality, and not the quantity, of learning opportunities. The second issue you address is the TYPE of work that doctors-in-training should be doing. I know you think that PAs and NPs should be doing all the "scutwork", but residents learn how the system works by performing some of these tasks and doctors enjoy enormous professional privileges that PAs and NPs don't enjoy upon entering the profession: namely, much larger salaries, more opportunities and more ass-kissing in general. It's fine with me if residents have to do a little scut work in order earn these privileges. Here in NM, NPs enjoy more autonomy than in other places of the country, and the amount of experience and training they have may make them more valuable to the patient and the rest of the health care team than newly-minted MDs. Why teach new MDs that they are meant for "higher" work purely on the basis of their title? Rather than wasting the talents of "physician extenders" on paperwork, why not fight for a system that minimizes paperwork for all and increases everyone's availability for meaningful work?

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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